Healing Machete Wounds with Safety Nurse- Origin Story Pt 3

I'm packing up to leave. I'm so tired of breathing in smoke, and I miss my kids and I know I have 24 hours of travel ahead of me before I will see them again. As I am giving Beatrice, the matriarch of the school and clinic in which I have been volunteering, a last hug, I feel a light tap on my shoulder. A thin, dusty man is standing behind me. He is with Beatrice's daughter, Fabiola who asks, "Would you have time to see one last wound?" I think to myself, "A person...a human being, not a wound" but that's nurse talk in my head, and I don't share. I motion the man over to a bench and he limps after me. He points to his right foot - he's wearing a black, equally dusty shoe with the part covering his toes cut off. I can see his bare foot, and I can see a large, brown, blob of mud on his great toe. He talks in Haitian Creole to Fabiola and I catch a few words, doulè (Pain), ede mwen (help me) and machete (machete). My Creole isn't great, but I definitely understand machete.

Fabiola explains that James was working in the fields last week, clearing brush with a machete and hacked part of his great toe off. It is hurting him, and he needs to get back to work - is there anything I can do? I ask Fabiola if I can have a basin of water and a cloth and while she gets that for me, I run to grab the wound care supplies I think I may need. What would you grab? Do you have a plan in place for dressing the wound you are expecting to see once the mud is washed away? I personally would want the following (at a minimum):

1. Gloves

2. Sterile saline - the kind that comes in a nice spray bottle

3. 4x4 gauze pads

4. Sterile gauze swabs for exploration, if needed

5. Sterile occlusive, non stick dressing (I love xeroform)

6. Tape

7. Bandages for wrapping

You have to work with what you have in Haiti, and I had most of the items on the list because we had brought them from the U.S. If we hadn't brought those items, I would have had a basin of clean water and some cloths.It takes about 15 minutes to remove the mud and what I see underneath is a great toe with a chunk missing. The medial upper part of the toe and some of the toenail is just gone. In place of what should be there is a reddish yellow area the size and shape of an elongated quarter, there is pus, and it doesn't smell very good, and some black, necrotic tissue around the edges (do yourself a favor and don't google "machete wound").

Ideally James would have gone to an emergency room or urgent care clinic, where they would have cleaned the wound, closing it if possible, so it could heal by primary intention. He would have been given a tetorifice shot if needed, and antibiotics to prevent infection. He would have been scheduled for a follow-up visit. James lives a 1 hour walk from the nearest clinic, which is only open a few hours a day, and which often has a line of 50 people outside upon opening its doors. When he hacked off his toe, he didn't have a way to get to town, and he needed to keep working to support his family.

His toe hurt, but he kept working and it eventually became so swollen that he had to cut his shoe to fit it over his foot. James didn't have the opportunity to take the day off, to elevate, rest and recuperate. James did not have access to bandages, or even socks. Now I have James in front of me with an infected wound that isn't healing. I would like to remove the necrotic tissue (not in an RN scope of practice, I know) and support healing by secondary intention with dressing changes and antibiotics. Instead, I applied Xeroform (iodine impregnated petroleum gauze) to the wound, wrapped it in gauze, secured it with tape, and then wrapped his foot in a long strip of gauze, which I secured with self-adherent wrap. I found the NP I was traveling with (who was busy with the million things she needed to do before leaving) and we gave him a week's supply of a broad-spectrum antibiotics (also brought from the U.S.) and asked him to go to the clinic the next day to have the wound cleaned and re-bandaged. Knowing he wouldn't come in all probability, I gave him some wound care supplies and told him to change the dressing every few days, or when soiled, or if it came off. James thanked me and we parted ways and within 36 hours I was back home in the US with all the wonders of modern medicine at my disposal. I have no idea what happened to James.

This is a story from my most recent medical mission trip to Haiti. I went in 2011, and then most recently in the fall of 2016 just after Hurricane Matthew. In 5 years, nothing appeared to have changed. I saw the same rubble and fallen buildings, the same deforested, barren, grey, dusty hills, the same grinding poverty. What difference was I making? Yes I was spending American dollars, but did Haiti really need ME? After I got back I had an idea. Why not do something that might actually make a difference? I decided to send a young Haitian woman to nursing school. Haitian women have a life expectancy of 62.8 years, but women in neighboring Dominican Republic live an average of 75.5 years. The infant mortality rate is one of the highest in the world at 630 per 100,000 live births. Women delay seeking treatment due to the time it takes to reach a clinic, the lack of available resources or physicians at clinics, and lack of funds. I came away from my second trip to Haiti with a renewed sense of purpose that if we don't help Haitians make a difference in Haiti, nothing will ever change.

The Patient Risk Detection Theory (Despins, et al., 2010)¹ states that education and training can reduce harm to patients. Additional research² shows that when we train WOMEN, we are even more likely to reduce harm. According to USAID³, investing in gender equality and women's empowerment can unlock transformational human potential. Women account for one-half of the human capital in any economy and Haiti is no different. Women make up more than 40 percent of the agricultural workforce, but only 3-20% are landholders. Only 22% of women in Haiti go on to Secondary school, but studies have shown an extra year of secondary school can increase future earnings by 10-20 percent. Countries investing in girl's education have lower mother/baby death rates, lower AIDS and HIV rates and better child nutrition. Polo Mitan, a Haitian Women's Organization, states that when women participate in politics, governments become more open, democratic and responsive⁴.

I chatted with the board of Consider Haiti (the local group I went to Haiti with in 2011)⁵ and they put me in touch with a 23 year old orphan named Rose Katiana L____. I started a business called Safety First Nursing⁶ to raise awareness about patient safety issues, and to raise funds for her education. I went ahead and sent her tuition to start school at the American University of Modern Sciences in Haiti in Saint-Marc (just outside Port Au Prince, but 45 minutes by Tap Tap from Montrouise where she lived). Consider Haiti helped me find a room to rent in St. Marc so she wouldn't have to make the long and death defying commute every day. I also sent her to English school (she started last summer). The funds to support Rose for the entire year of school (including room, board, uniforms, books etc... has been $3000), though I am worried because I don't think she gets to eat every day.

Rose's first day of school was November 27^th, 2017 - here is what she wrote (translated from Creole)

How are you going? I write you to tell you I'm really happy for going school. It is the first week of school, the teachers get acquainted with the students. There are amongst our teachers who are advising on the extent of the nurse's career. As a nurse, if you don't know it, the doctor may. I have learned some things about STDs (sexually transmitted diseases) and I have learned some about IST (sexually transmitted infections). I also learn to understand the difference between an infected person and someone who is sick. I learn someone can get infected but not sick. Someone is sick when it comes to signs and symptoms. I hope to learn more because I want to learn. Here is the STD day plan: 1) Definition of word updating STD 2) different types of STDs 3) how the STI transmits 4) Factors that favor the transmission of STDs 5) how to prevent STIs. I will start sending photos and videos of my fellow students. If there is a type of photo you need to ask me to read and send it to you. I am happy to go to school to learn how to work with you. I will never stop thanking you so I can begin to fulfill my dreams. Thank you very much!

This is her most recent email to me in late January, 2018 (in English!):

How are you? I'm happy to write to you. I've Just taken an exam lately and I'm passed and qualified for the next session. I love the teacher's way of teaching. I feel so good when I' m in the school now. Love you!!!!

It is my deepest wish that Rose carries my passion for nursing to the people of Haiti. I am excited to see where empowering her will lead. She is becoming Safety Nurse in Haiti (If you didn't get a chance, you can read the first part of the origin story of Safety Nurse HERE). Please consider supporting medical mission work and real change in Haiti. You can visit Safety First Nursing⁶ to see pictures of Rose, sign up for my newsletter to get updates and donate to her tuition fund. There are even some CEUs there - all purchase funds go towards her tuition, room and board.

Read the complete story:

The Origin Story of Safety Nurse: How I Got Here. Pt 1

Safety Nurse in Haiti: A Medical Mission Trip- Origin Story Pt. 2

Healing Machete Wounds with Safety Nurse- Origin Story Pt 3

References

1 Detection of patient risk by nurses: a theoretical framework. - PubMed - NCBI

2 Progress of the World's Women, 2015-2016 United Nations Report

3 USAID Empowering women

4 Poto Mitan - Haitian Women - Pillars of the Global Economy

5 Consider Haiti

6 HOME - Safety First Nursing